Provider Demographics
NPI:1063281210
Name:GUSTAFSON, LUCY ANN (DC)
Entity type:Individual
Prefix:
First Name:LUCY
Middle Name:ANN
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:LUCY
Other - Middle Name:ANN
Other - Last Name:KOCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:470 HIGHWAY 96 W STE 130
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-1996
Mailing Address - Country:US
Mailing Address - Phone:651-252-1912
Mailing Address - Fax:
Practice Address - Street 1:470 HIGHWAY 96 W STE 130
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-1996
Practice Address - Country:US
Practice Address - Phone:651-252-1912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-29
Last Update Date:2025-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7163111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor